The Fatal Four: Aspiration's Dangers and Key Interventions

When a person inhales contents from the stomach from the oropharyngeal area, such as food or liquids, into the trachea, it is called aspiration. Aspiration is a major medical concern for anyone because it may cause different types of pneumonia, infection, pulmonary emboli or other issues. Among people with intellectual and developmental disabilities (IDD), the risk of aspiration is heightened, especially if a person has trouble controlling the muscles involved in swallowing. This makes aspiration the final condition in the “Fatal Four.”

Prevalence of Aspiration Among Individuals With IDD

The biggest complication from aspiration is aspiration pneumonia, which accounts for up to 15 percent of pneumonia cases contracted outside of hospital settings, reports Healthline. In addition, aspiration pneumonia is common following an incident of aspiration. In other words, the likelihood of being diagnosed with aspiration pneumonia is extraordinarily high among people who suffer from aspiration.

The prevalence of aspiration in those with IDD varied slightly between developmental disabilities as well.

For example, a study conducted on the risk of aspiration among people with down syndrome (DS) found up to 84.6 percent of participants experienced a heightened aspiration risk during swallowing evaluations, reports the Journal of Neurology and Neurobiology. However, the general risk of aspiration among individuals with DS was nearly equal to the highest-risk populations outside of intellectual disability or developmental disabilities.

Another factor in the prevalence of aspiration can be found by analyzing the rates of dysphagia among people with IDD. Dysphagia describes general swallowing difficulties, and in multiple studies, explains the U.S. National Library of Medicine and Medscape, the prevalence of aspiration was increased in those suffering from dysphagia. More importantly, the overall risk of contracting aspiration pneumonia was reiterated in those who had trouble swallowing due to birth defects. In other words, a person with any IDD is significantly more likely to suffer from dysphagia and aspiration at some point.

What Are the Symptoms of Aspiration?

Defining the symptoms of aspiration is difficult. In a sense, the only way to recognize possible aspiration officially is through medical imaging and diagnostic testing, such as blood tests or X-rays. However, the symptoms of aspiration pneumonia can allude to an earlier incident of aspiration that was not treated or has not been resolved fully. These symptoms include the following:

Chest pain

Shortness of breath

Fatigue

Cyanosis (facial pigmentation starts to turn blue).

Cough, especially involving bloody or green sputum.

Bad breath.

Difficulty swallowing.

Excess perspiration.

Fever.

The bolded symptoms may appear following an incident of aspiration, but they do not always appear after every aspiration. Consequently, a person could aspirate while alone, and direct support professionals (DSPs) may not recognize other symptoms, such as fever, until pneumonia has set in.

What to Do If Aspiration Is Suspected

Unfortunately, there is not a one-size-fits-all means of recognizing when someone aspirates. Generally, any incident involving choking on food or drinks, a so-called “going down the wrong way,” could indicate aspiration. The immediate course of action is to eliminate the source of the content being aspirated. In other words, a person experiencing minor choking should be encouraged to spit out food or beverages, and if the source of aspiration is vomiting, prevent the person from lying on his or her back.

For example, if a person vomits during a seizure, another of the “Fatal Four,” putting him or her on the back can help prevent vomit from entering the trachea, causing aspiration.

How to Help Prevent Aspiration

All caregivers and DSPs can take certain steps to help prevent the risk of aspiration. However, those with higher functioning cognitive abilities must be made aware of activities that increase risks for aspiration, such as drinking to excess or drinking while under the influence of sedatives or other medications.

Other steps to prevent aspiration include the following:

Avoid taking too many sedatives at once. This is not only dangerous due to overdose, but it can impair a person’s judgment and ability to react if he or she vomits or chokes.

A person who experiences a choking incident or possible aspiration should avoid consuming liquids or foods until evaluated by an authorized medical professional.

A swallowing evaluation can help identify the level of aspiration risk a person has. A licensed speech therapist commonly conducts this type of evaluation.

Occasionally, those with intellectual disability may “pocket” foods in their cheeks. This can lead to trying to swallow too much food at one time, causing choking and possible aspiration. If a person requires assistance while eating, ensure he or she is not pocketing food.

When providing assistance while eating, take your time. Getting in a rush to help a person eat faster will dramatically increase aspiration risk.

Encourage those you serve to thoroughly chew their food. If chewing food properly is not physically possible, a mechanically soft or puree diet may be an option, but this is at the discretion of the speech therapist, nutritionist and physician.

Thickener may also be used to help prevent aspiration when consuming liquids.

Esophageal spasms, such as those caused by severe acid reflux, should be treated to help prevent aspiration.

Any dental problems must also be addressed. This goes back to chewing food properly.

Speech therapy may help reduce aspiration risk as well.

Final Thoughts on the "Fatal Four."

Aspiration makes up the final condition in the “Fatal Four” health problems that occur more frequently among people with intellectual or developmental disability. As with seizures, dehydration and constipation, untreated aspiration could result in dehydration or constipation. In other words, a person who is sick with aspiration pneumonia may not want to eat or drink, or he may not be able to swallow foods properly in the immediate aftermath.

The only solution to preventing the “Fatal Four” from claiming more lives is prevention and education. DSPs and other caregivers in your organization need to understand how the “Fatal Four” interact and how they can lead to other serious health problems. Since those with intellectual disabilities may not be able to express themselves, the task of monitoring for warning signs of the “Fatal Four” is even more important. If you fail to understand these health conditions today, it could cost someone’s life. You have a duty to do everything you can to help those you serve.

Working in health care since 2005, Jason's body of experience encompasses dozens of care settings, including Senior care, psychiatric facilities, nonprofit health service centers, group homes for those with developmental disabilities and beyond. Jason understands the need to tailor his skills to each setting to encourage the best treatment outcomes and promote an inclusive, healing environment.